The community as an active part in the implementation of interventions for the prevention and care of tuberculosis: A scoping review

Interventions involving direct community stakeholders include a variety of approaches in which members take an active role in improving their health. We evaluated studies in which the community has actively participated to strengthen tuberculosis prevention and care programs. A literature search was performed in Pubmed, Scopus, ERIC, Global Index Medicus, Scielo, Cochrane Library, LILACS, Google Scholar, speciality journals, and other bibliographic references. The primary question for this review was: ¿what is known about tuberculosis control interventions and programs in which the community has been an active part?. Two reviewers performed the search, screening, and selection of studies independently. In cases of discrepancies over the eligibility of an article, it was resolved by consensus. 130 studies were selected, of which 68.47% (n = 89/130) were published after 2010. The studies were conducted in Africa (44.62%), the Americas (22.31%) and Southeast Asia (19.23%). It was found that 20% (n = 26/130) of the studies evaluated the participation of the community in the detection/active search of cases, 20.77% (n = 27/130) in the promotion/prevention of tuberculosis; 23.07% (n = 30/130) in identifying barriers to treatment, 46.15% (n = 60/130) in supervision during treatment and 3.08% (n = 4/130) in social support for patient. Community participation not only strengthens the capacities of health systems for the prevention and care of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient and the affected community by identifying barriers and difficulties through of the tuberculosis care cascade. Engaging key community stakeholders in co-creating solutions offers a critical pathway for local governments to eradicate TB.


Introduction
Tuberculosis(TB) is an infectious disease that, despite being a preventable and curable disease, continues to be a problem for global public health, with an estimated of 1.6 million people died from this disease in 2021 [1].In addition, ending tuberculosis has become a greater challenge as it is related to other diseases such as the human immunodeficiency virus (HIV).In tuberculosis epidemiology, the social determinants of health in a community such as poverty, overcrowding, inadequate housing conditions, malnutrition, etc. they exert a clear influence on all stages of tuberculosis pathogenesis (risk of exposure, time to diagnosis, treatment, susceptibility to disease progression, and retention in care) [2,3].Therefore, tuberculosis is a social disease that requires the involvement of the community to propose joint solutions with the local government [4].
To ending TB, one of the strategies used is Directly Observed Therapy, Short Course (DOTS) [5].This strategy has been administered under the guided supervision initially by health workers, but over the years it has also included community volunteers and members of patients' families.This has led to gradually include the community in the tuberculosis prevention and care activities.This community participation has been escalating to other levels such as the detection and active search of person with presumed tuberculosis, and this participation helps to generate greater linkage of patients with TB care centers and to increase the retention in care of detected cases [6].
Over the years, community participation in programs aimed at preventing and eliminating tuberculosis has made significant progress, enabling them to be integrated into strategic plans such as Directly Observed Treatment (DOT), Stop TB, and End TB [7][8][9][10].The World Health Organization (WHO) approach, called "ENGAGE-TB", emphasizes that community participation is fundamental to improving the reach and sustainability of tuberculosis services for the community.This approach allows the implementation of integrated community TB activities within health programs, and WHO provides technical guidance, community training, and encourages the creation and development of alliances between tuberculosis care programs and civil societies [11,12].Furthermore, the fifth component of the Stop TB Strategy emphasizes the importance of communication, advocacy, and social mobilization in enhancing case detection, treatment adherence, empowering individuals affected by TB, combating stigma and discrimination, mobilizing political commitment, and allocating resources for tuberculosis prevention and care [7].Moreover, community engagement in research is encouraged, thus contributing to the strengthening of tuberculosis prevention and care programs.An example of this effort is the TB Alliance, which is an association that works with people affected by tuberculosis, who train and empower them to improve their knowledge and skills to participate in tuberculosis drug research by creating an extensive network of Community Advisory Boards (CABs).This community outreach initiative makes it possible to create links between clinical trial participants, community members and academic researchers to achieve mutual feedback based on open and consensual dialogue [13].
Community-based participatory research (CBPR) is an approach in which the community is engage in all stages of research from conception, design, execution, implementation and follow-up of research [14].CBPR allows for the creation of collaborative, equal partnerships between community members and academic researchers.Furthermore, this research approach was raised with the need to reduce communication and operational gaps that frequently imply failure for traditional research that often omits the complex cultural, social and economic interrelations and their impact on the effective implementation of interventions [14][15][16][17].CBPR can be used for all study designs, from qualitative studies to randomized clinical trials [14].To our knowledge, there are only two reviews by Arshad et al. [6] and Musa et al. [18], who evaluated the effect of community-based interventions for tuberculosis prevention and care and have reported potential benefits to include the community in TB research studies.However, it is currently unknown to what extent community engagement can generate benefits for health programs focused on tuberculosis ending considering the principles of CBPR (recognize the community as a unit of identity, draw on the strengths and resources of the community, facilitate collaborative partnerships, integrate knowledge and action for the mutual benefit of all, promote a process of co-learning and community empowerment, engage a cyclical and iterative process, addressing health from a comprehensive and ecological approach, and disseminating the findings and knowledge acquired to all partners).Also, it is unknown what have been the mechanisms that have been used to strengthen communities in their participation and what has been the impact of the inclusion of the community for tuberculosis prevention and care.Based on this, our review aims to assess the characteristics of interventions in which the community has genuinely taken an active part in the development and implementation of research studies to strengthen tuberculosis prevention and control programs.

Study design
We carried out a scoping review following the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [19] (S1 File) and a protocol that was carried out priori, based on the following research questions: Primary question: ¿What is known about tuberculosis control interventions and programs in which the community has been an active part in the development and implementation of the study?
Secondary questions: a) ¿What strategies are being used to strengthen the participation of communities in interventions and programs for tuberculosis control?and b) ¿What opportunities, lessons learned, and challenges are there in the sustainability of community-driven interventions and programs?
The protocol is available in S2 File.This scoping review followed the five-stage methodological framework that was developed by Arksey and O'Malley [20] and an additional sixth stage developed by Levac et al. [21], these stages are as follows: 1) identify the question research, 2) identify relevant studies, 3) select studies, 4) record data, 5) collate, summarize and report results, and 6) consult with relevant stakeholders.

Data sources and search
To identify the studies, we systematically searched Medline (through Pubmed), Scopus, ERIC (Education Resources Information Center), Global Index Medicus, Scielo, Cochrane Library and LILACS (Latin American and Caribbean Literature in Health Sciences).A search of the gray literature was performed through Google Scholar and MedRxiv.In addition, we performed a manual search identifying the journals of internationally recognized organizations in tuberculosis (S3 File) and by reviewing the bibliographic references of the review articles and included studies.Search terms such as "Community-Based related", "Community-based interventions", "participatory action research", "participatory engagement", "Community Participation" and "tuberculosis" were used (the complete list of search terms can be found in the S4 File).The choice of terms and search strategies were developed and refined through a discussion with the research team (S5 File).All the searchs were done until 15 july 2023 and was updated the Medline (through Pubmed) search until 30th April 2022.For the importation of articles and the elimination of duplicates, the reference manager used was Endnote X9 (Clarivate).

Selection criteria
This scoping review included studies that describe or analyze the role of direct involvement of key community members in the development and implementation of tuberculosis prevention and control programs.We included studies such as randomized clinical trials, non-randomized trials, observational studies and preprints in which the community actively participated in a research study or programs focused on the prevention, diagnosis, treatment, and elimination of tuberculosis (planning the idea, design, implementation, monitoring, and evaluation of interventions).We conducted a search of all-time published studies in Spanish and English.We excluded editorials, expert opinions, review articles, book reviews, or conference abstracts, and traditional studies in which the community was only considered a means to respond to the study's objective.

Screening, collection, and processing of data
One reviewer (LCR) performed initial title identification and duplicate removal using an Endnote X9 (Clarivate) reference manager.Before starting the study selection process, a calibration process was carried out between two reviewers (LCR and MJB) with 10 randomly selected studies to select the studies according to the eligibility criteria.Subsequently, in a first phase, a selection of the studies was made based on the titles and abstracts; and in a next phase, a fulltext evaluation was carried out according to the eligibility criteria.All these processes were closely supervised by a researcher (MJB).
For data extraction, the "descriptive-analytic" method was used, which consists of applying a common analytical framework to all included studies and collecting standard information from each study [20].In addition, to carry out the coding of the information, a full-text evaluation of the included articles was carried out based on the research questions.The "inclusion of the community in research" and the "strengths of community participation" will be extracted from the methods section of the scientific articles and the evaluation of the "sustainability of the interventions" from the discussion section of the primary studies.
The results were presented in tabular diagrams.For coding the level of community participation in the interventions, we referred to the systematic review conducted by George AS et al. [22] In this review, community participation was evaluated based on five key elements: identification and definition of addressed problems, interventions to address these problems, implementation of interventions, management of resources, and monitoring/evaluation of interventions.Furthermore, we summarize the evidence for the different modalities of the participation of community members in the different aspects evaluated of the pulmonary tuberculosis care cascade, such as in the prevention of tuberculosis (health education, BCG vaccination and/or administration of chemoprophylaxis), detection and active case finding, results and adherence to tuberculosis treatment (identification of barriers and difficulties for tuberculosis treatment/supervision and surveillance during tuberculosis treatment), implementation of interventions for ending tuberculosis and social support and support programs for patients affected by tuberculosis.To be included in this scoping review, the articles had to involve community participation in at least one of the stages of the tuberculosis care cascade.Regarding the secondary questions, we coded information on how the community has been strengthened in their participation in studies or programs focused on the prevention and care of tuberculosis; and finally, we coded information from studies that evaluated the sustainability of interventions or programs (intervention or program that continues to be implemented after a defined period of time while adapting).
In addition, we evaluated those studies that by involving the community complied with all the principles of CBPR.Research with CBPR methodology is based on the principles of participatory and equitable community participation in all research processes and shared ownership of problem identification, development, and research products [17,[23][24][25].The fundamental principles of the CBPR approach are as follows: recognition of the community as a unique identity, builds on the strengths and resources of the community itself, promotes collaborative/equitable teamwork, facilitates mutual learning and capacity building through a process of continuous empowerment, integrates and establishes a balance between the generation of knowledge and action, a cyclical and iterative process is used, it allows evaluation by addressing health problems in the community with a comprehensive and ecological approach, it disseminates results to everyone: the academia, local governments, NGOs and community members.These principles are adapted to the sociocultural context of the communities [14,15].

Literature search
Our scoping review initially identified 2077 titles and abstracts.Of these studies, 1624 studies were excluded based on our eligibility criteria.453 full-text studies were evaluated, of which 175 studies finally met the pre-established inclusion criteria.The study selection flowchart is presented in Fig 1.

Characteristics of the articles included
Of the included studies, over the years, there has been a gradual increase in the amount of research in which the community has been actively involved in ending tuberculosis.The studies identified in our review were conducted in all WHO regions, mainly in the African region (46.3%, n = 81/175), the Americas (17.7%, n = 31/175), and in Southeast Asia (20.0%, n = 35/ 175).In relation to the types of articles, the most frequent were the quantitative ones (45.7%, n = 80/175) followed by the qualitative ones (33.1%, n = 58/175) and finally the mixed methods (14.3%, n = 25 /175).These characteristics are presented in Table 1.
In relation to the questions raised in this scoping review, we divided the results into three sections.The first is about the nature of community participation and community involvement in the implementation of interventions aimed at the different stages of the tuberculosis care cascade.The second section is about the strategies that have been employed to strengthen community participation in research and/or programs focused on tuberculosis elimination, and the third section is about the sustainability of interventions in which the community has played an active role in their development and cost-effectiveness studies of these interventions.

Nature of active community participation in the included studies
The participation of communities in research studies on tuberculosis has been evaluated and categorized considering the classification of the study by George AS et al. [22], who evaluated the degree of community participation in research on interventions in health systems in lowand middle-income countries through five different elements:  elements.Details of the nature of participation through these five elements are presented in Table 2.

Active community participation in the implementation of interventions
In the included studies, community participation in the development of research studies in the different stages of the tuberculosis care cascade or as part of a program for the prevention and care of tuberculosis was identified in the following scenarios: 28.0% (n = 49/175) of the studies included the community on activities related to the prevention of tuberculosis, 29.1% (n = 51/ 175) of the studies involved the community in the detection and active search for tuberculosis cases.The 24.0% (n = 42/175) of the studies in the identification of barriers and difficulties for the antituberculosis treatment, 44.0% (n = 77/175) of the studies on supervision and surveillance for tuberculosis treatment and 4.0% (n = 7/175) of the studies evaluated the participation of the community in social support and support for the affected patient for tuberculosis.Finally, it was identified that 13.1% (n = 23/175) of the studies evaluated the participation of the community in other related aspects such as greater understanding of the disease, identification of factors related to the search and quality of care for patients affected by tuberculosis and studies that explored the experience of community health workers in ending tuberculosis (Table 3).
On the other hand, over the years, one of the factors that possibly increased community participation was the joint management of HIV-TB.We found that 16.6% (n = 29/175) of the studies evaluated this joint planning of HIV-TB activities.Most of these studies were conducted in Africa (n = 21/29), followed by the Americas (n = 4/29) and Southeast Asia (n = 2/ 29).Only one study was reported that evaluated joint management and planning for the management of diabetes and tuberculosis [26].On the other hand, 32.6% (n = 27/175) of the Regarding the activities carried out by the community, we found that they performed tasks such as research assistants in some of the different stages of the investigations, such as recruiting participants for research, executing the implementation of interventions (for example, evaluating some epidemiological indicators such as the prevalence of tuberculosis in their community, leading focus groups to identify gaps, difficulties, and opportunities in tuberculosis prevention and care, taking surveys to assess the level of knowledge about tuberculosis in their community, conducting educational activities on tuberculosis prevention and care, conducting active case finding, assisting in expediting the processes for timely diagnosis of tuberculosis, evaluating adherence to antituberculosis treatment, and performing follow-up tasks for patients providing social and emotional support).They have even performed tasks to train other community members to become future health promoters in their community.They did this by involving the community through opinion leaders and grassroots organizations.

Strengthening of community participation in included studies
5.1% (n = 9/175) of the studies included in our review used the community-based participatory research approach.However, only half (n = 4/175) of these studies complied with the CBPR principles.On the other hand, 32.6% (n = 57/175) of the studies carried out some type of education or training for community workers to carry out their functions in tuberculosis research studies.

Sustainability and cost-effectiveness evaluations of the included studies
4.6% (n = 8/175) of the studies evaluated the sustainability of the interventions in which the community had participated.In addition, 2.31% (n = 3/130) of the included studies evaluated the cost-effectiveness of community participation in tuberculosis care [27][28][29].Khan et al. [27] reported that self-administered treatment was the most cost-effective ($164 per patient cured).However, they had a 62% cure rate as opposed to DOTS administered by community health workers (CHW) ($172 per case cured), which had a 67% cure rate.DOTS supervised by a family member ($185 per patient cured) had a cure rate of 55% and finally DOTS administered in a health center ($310 per patient cured) had a cure rate of 58%.Sinanovic et al. [28] reported that for new patients community-based DOTS was more cost-effective ($726 per successfully treated patient) than no directly observed treatment ($1201 per successfully treated patient).Similarly, for retreatment patients, community-based DOTS was more cost-effective ($1,419 per successfully treated patient) than no directly observed treatment ($2,058 per successfully treated patient).Finally, Prado et al. [29] reported that the cost per patient treated with DOTS supervised by tutors was $398 and for DOTS supervised by CHW it was $548.
All the studies included in our review (quantitative and qualitative) showed positive effects of community participation in the different stages of tuberculosis prevention and care.In addition, the authors reported that community participation improved various aspects of the research from study planning, intervention implementation, evaluation, and participant follow-up.For example, the recruitment of participants was expedited, and the collection of sensitive data more precisely, the adherence of the participants to the study, among others.This is because the patients had greater confidence in the CHW.Although, indeed, the results are not yet conclusive and more studies are required that are adequately designed and adapted according to the different sociocultural and economic contexts of each country or region, community participation has been and will continue to be part of the progress and strengthening tuberculosis prevention and care programs.

Discussion
In our scoping review, we identified 175 studies that reported genuine involvement of community members.Most of these studies were conducted in Africa (46.3%), the Americas region (17.7%), and Asia (20.0%).According to the 2022 Global Tuberculosis Report, the highest burden of tuberculosis disease occurs in the Asian and African regions (69%) [30].This could explain the reason for the higher frequency of studies found in these continents.This scenario is different for the region of the Americas, in which its global burden of tuberculosis is 2.9%, but it is the region with the second most studies that attempt to involve the community as part of their strategies to end tuberculosis.However, most of these studies are carried out in populations with a high burden of tuberculosis, such as in Latin American and Caribbean countries [31].
The results of our scoping review suggest that active community participation contributes to strengthening tuberculosis prevention and care programs.We found that the community was mainly involved in identifying needs, risk factors, and/or problems (63.4%); and in implementing interventions (52.0%).On the other hand, we found that the community mainly participated in the supervision and monitoring of anti-tuberculosis treatment (44.0%), in identifying barriers to treatment (24.0%), prevention (28.0%), and active case finding (29.1%).This highlights the need to move away from the traditional scenario of scientific research, which is directed solely by academic researchers.Instead, we should consider a comprehensive and ecological approach that also involves the community and other social actors as key players in identifying problems and developing joint solutions that reduce the social and economic gaps that contribute to the burden of tuberculosis.This is similar to what was mentioned by Arshad et al. [6], who reported that community-based interventions increased the probability of tuberculosis case detection (RR: 3.1; 95% CI: 2.92 to 3.28) and success rates of treatment (RR: 1.09; 95% CI: 1.07 to 1.11).Also, they reported that the CHW, by delivering the treatment, not only increased and improved the conditions for access to care for patients affected by tuberculosis, but also improved the registration and notification systems for tuberculosis cases.Yassin et al. [32] implemented a community-based TB intervention package to bring diagnostic and treatment services closer to vulnerable communities.They reported that community participation doubled tuberculosis case notification rates and improved treatment outcomes.Similarly, other studies have reported that active case finding in countries or places with a high TB burden by CHW, community volunteers, and trained family members could strengthen notification systems and reduce gaps in access to information and health care in the community.Active case finding of smear-positive cases made an important contribution to the success on diagnosis and care of tuberculosis.This is significant because tuberculosis patients frequently present to health facilities when their disease has worsened, and this is a major limitation in global efforts to ending tuberculosis [33][34][35][36][37][38][39][40][41][42][43].
With respect to TB treatment outcomes, better results have been reported when DOTS has been delivered by CHWs, allowing for higher treatment success rates.In addition, CHWs have contributed to the supervision and follow-up for cases of drug resistance and support to patients throughout the treatment phase.
Regarding strategies to strengthen community participation, we found that only 4 studies involved the community in all phases of the research and allowed for closer engagement between the community and academic researchers [15,[44][45][46].
In studies with a CBPR approach, academic researchers often establish a community advisory board (or CAB), which is made up of community members who represent the voices of the community regarding their perceptions, preferences, talents, etc. and priorities.These community partners can be community health centers, public health departments, schools, prisons, and civil society organizations such as neighborhood organizations [14,47,48].A case of collaborative association with a CBPR approach is a study that we carried out on the population affected by TB in Peru in collaboration between the Universidad Peruana Cayetano Heredia, Ohio State University, and the Association of Tuberculosis Patients of Comas [ASET] (Comas, district of Peru with a high rate of tuberculosis) [49].In the first phase, we conducted an empowerment program for CHW in ASET through research training, and in the second phase, we implemented an intervention led by CHW to assess the effect of social determinants of health in tuberculosis in the population affected by TB.
The inclusion of strategic research partnerships that allow the establishment of an equal relationship between the community and academic researchers requires time and financial resources [50].In low-and middle-income countries, CHWs are a key component of the health workforce to achieve the Millennium Development Goals [51].However, CHWs face many challenges such as high turnover in their functions, low motivation, inadequate supervision, lack of resources available so that they can carry out their functions, insufficient compensation or incentives, and little recognition and involvement on the part of health care providers.All of this limits their ability to contribute effectively to primary health care [52].
Among the reported functions of TCS in the included studies were determining epidemiological indicators such as tuberculosis prevalence in their community, leading focus groups to identify gaps, difficulties, and opportunities in tuberculosis prevention and care, providing health education (increasing awareness and knowledge about tuberculosis), detecting, and actively searching for cases, supporting timely diagnosis processes, evaluating treatment adherence, and patient follow-up.However, CHWs have not only been involved in the afore mentioned functions, but have often solved problems that are ignored by TB programs, such as providing personalized moral comfort, nutritional support, and stigma reduction for patients affected by tuberculosis [53].Among the motivating factors for CHW are satisfaction for helping people affected by tuberculosis (feeling of prestige related to helping the neighbor), having a good relationship with health workers, respect for the community and the personal benefit they find by learning new information about tuberculosis and general health.The latter was the main motivating factor for CHWs as it empowered both them and the patients about their health and that of their community [54].In addition, CHWs can decrease the stigma of tuberculosis disease because it by drawing on their own personal experiences about the disease they can increase openness and decrease stigma among people [4,55,56].
On the other hand, only 32.6% of the studies provided training to CHWs so they could perform their functions, which were varied but mainly focused on implementing interventions.However, most of these studies only trained them to perform a specific function within the research study.
Reyes et al. [56] was the only included study that carried out a training program for community promoters for the prevention and care of tuberculosis in Mexico.This study empowered its promoters through educational and participatory workshops to improve understanding of the disease and about the prevention and treatment of the disease.
On the other hand, the active participation of the community was reflected in their performance as research assistants (or participation in some phase of the study) when developing tasks such as recruiting participants, implementing interventions (providing treatments, conducting faculty groups, etc.), data collection (for example sampling, surveys, etc.), monitoring of participants, providing health education to patients, among others.This not only helped streamline research processes but could also improve the accuracy of the information collected and the validity of the results.Furthermore, forming these links between researchers and the community improves and re-establishes trust for future research.
In relation to sustainability and cost-effectiveness studies of interventions, the sustainability of interventions are those programs that continue to be implemented after a defined period of time while they are adapted and adapted to continue producing benefits for people [57,58].Sustainability is an important component for the implementation and dissemination of health interventions and for the evaluation of their effects in the medium and long term.However, it is frequently poorly documented [23,59].Lwilla et al. [60] mentioned that the DOTS provided by CHWs was practical and sustainable because it allowed optimizing the time of some health workers for other duties, especially in an environment with a large increase in notification of tuberculosis cases.Dudley et al. [61] reported that at 6 years, community-based tuberculosis care was maintained despite the increasing number of patients requiring care.In addition, through this time the number of CHWs increased.However, the replicability of this model varies across community settings.In more complex urbanized settings, a barrier encountered is that health services are managed without the support of community organizations.Therefore, interventions with active community participation depend on the availability of organized community-based structures that can provide their resources and support health systems.Similarly, Wieland et al. [23] conducted a case study reporting the sustainability of a tuberculosis prevention and control program (case detection) at the adult education center of the Rochester Public Schools district.They report that this intervention has been sustained for 8 years due to the collaborative work of the education center, public health department, and the Rochester Healthy Community Association, whose mission is to promote health through a CBPR approach.On the other hand, Han et al. [62] mention that community tuberculosis prevention programs can be sustained over time when CHWs are trained and social mobilization groups are formed.Considering this evidence, community participation has been shown to lead to significant changes in ending tuberculosis.The community's confidence and empowerment in their own resources and capacities allows them to work differently to address complex problems such as tuberculosis.
On the other hand, regarding the cost-effectiveness studies of DOTS provided by CHWs, the studies showed that DOTS provided by CHWs were more profitable and more cost-effective over time.In addition, CHWs not only provide treatment but also provide primary health education, vaccination, monitoring of risk groups, emotional support, and other social services for the benefit of people with TB and their families [27][28][29].Therefore, DOTS provided by the community demonstrates that it is an alternative that can be used for the programs by ending tuberculosis.
Therefore, TB programs that consider the community as an important part of their activities need to establish sustained communication (system for contacting volunteers) and frequent contact with the community organization.In addition, the CHWs must receive feedback on the progress of the program, as well as be involved in any changes or new initiatives.In addition, the empowerment of CHWs allows them to train new volunteers to carry out the activities [6].

Strengths and limitations
This scoping review has some limitations.We made an identification of studies published in English (97.69%) and Spanish (2.31%) because the largest source of evidence is presented in those languages.We do not rule out the possibility of having studies that meet our eligibility criteria and that have been published in other languages.However, a comprehensive search was performed in recognized health databases, a gray literature search was performed, and studies were collected through the literature search and contacting authors for more information.In addition, a critical evaluation of the design of the included studies was not carried out, which limits the evaluation and characterization of the quality and certainty of the evidence that makes it possible to visualize the methodological bases of the current evidence on this topic.It would be important that this be evaluated in future systematic reviews.However, we believe that our study, by synthesizing current evidence on interventions or studies in which the community has actively participated in their development and/or implementation, adds additional value for local and local tuberculosis prevention and care programs to consider the community as a fundamental part of the strategies to achieve their goals of eradicating tuberculosis [63].

Future research
Based on our scoping review, we have identified that there is a paucity of information from studies that comply with the basic principles of CBPR in the population affected by tuberculosis.In addition, more studies are required to evaluate the cost-effectiveness and sustainability of community participation interventions in ending tuberculosis in the long term.Strategic CBPR research partnerships can mobilize and organize larger-scale community efforts to establish policies that enable social and economic policy change needed to achieve health equity [14,64,65].

Conclusions
Direct community engagement in tuberculosis prevention and care in research with a community-based participatory research (CBPR) approach has not been consistently reported.However, according to our analysis, the studies found show that the active participation of the community presents a positive tendency towards the strengthening of programs for the prevention and care of tuberculosis.In addition, the participation of key members of the community not only strengthens the capacities of the health systems to generate strategies and action plans for the prevention and care of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient by identifying barriers and opportunities along the cascade of care for patients affected by tuberculosis in the 'Global South'.This scoping review also makes it possible to show that there is a need to carry out studies with the CBPR approach in the population affected by tuberculosis due to the large social component, such as the social determinants of health, that affects this disease.This seems to indicate that studies are required that restructure the focus of a traditional investigation to one with a CBPR approach, where the population is considered as an end for the objectives of the study.The active participation of communities in co-creating solutions goes beyond the biomedical sphere and offers a critical path for regional and local governments in the fight to eradicate tuberculosis.
Fig 1 includes the processes of identification and selection of studies according to the eligibility criteria.

S4File.
Search terms and keywords.(DOCX) S5 File.Search strategies in each database and information repository.(DOCX) S6 File.Spanish version of the manuscript.(DOCX)

Table 3 . Active community participation in the implementation of interventions aimed at the different stages of the tuberculosis care cascade.
developed between 2021 and 2023 (during the COVID-19 pandemic), being carried out mainly in Africa (42.1%) followed by Southeast Asia (19.3%) and Western Pacific (11.0%).
ACP: Active community participation.*Studies in which the community has participated to understand the disease, factors associated with seeking care, and experiences of community participation.https://doi.org/10.1371/journal.pgph.0001482.t003studies were